Yemi, an 18 –year old clerk has not had a period since her last D & C (standard abortion procurement) six months earlier, her fourth D& C since the age of 15 years. Each was done after she had missed her by about seven to ten days. No prior clinical examination of pregnancy test was done or even suggested. No counselling was given. We later found that Yemi had Asherman’s syndrome- a complication of D & C that may make her infertile. Was Yemi ever pregnant or not?
Menstruation is the outward manifestation of very complex series of chemical, hormonal and physical changes which occur in the female in anticipation of and preparation for normal pregnancy. If conception fails to occur, the lining of the womb is shed.
This shedding is menstruation. It is therefore described as the weeping of a disappointed womb. Pregnancy is thus the commonest cause of a missed period. HOWEVER THERE ARE OTHER CAUSES OF MISSED PERIOD especially in adolescence – I have emphasised this because many young girls like Yemi have gone to “procure abortion” or have been encouraged to “procure an abortion” by all sorts of practitioners in the country, simply because they missed their period. The need to confirm pregnancy before a decision to keep or terminate it cannot be over-emphasised. This, will definitely save many a young lady tremendous agony and misery in later life.
Menstruation is only one of the many changes that occur in adolescence. Adolescence is characterised not only by the magnitude and rapidity of physical changes of sexual maturation but also by an important process of psychic maturation. There are qualitative and quantitative changes in the sexual drive, affecting the behaviour of the adolescent. A change in role from dependent child to independent autonomous adult slowly occurs.
Psychological factors also have significant influence on the rhythm of menstruation. The normal menstrual cycle that is from the first day of the period to the first day of the next period is 28days plus or minus seven days (i.e. a range of 21 to 35 days). There is significant person to person variation in the length of the cycle and sometimes there is variation in cycle length in the same individual in the absence of disease or pregnancy. Irregular menstruation may present as infrequent menstruation (Oligomenorrhoea) where the length of the cycle is increased or as very frequent menstruation in which case the cycle length is shortened (Polymenorrhoea). In the adolescent age group, other abnormalities of menstruation worthy of mention would include: – excessive menstrual bleeding menorrhagia delay in onset or failure to start menstruation, and painful menstruation. Due to the very complex nature of the control of menstruation and the other factors which affect it, including emotional factors, the early periods may be very irregular and many of them are not associated with ovulation. It is not unusual for a young girl to have her menarche (first period) and not have another for months. It becomes regular after two to three years and would have regularised in most people by the age 18 years. In a small number of people, the periods however will remain infrequent even after the age of 20.
In this group of people in whom spontaneous conversion to regular cycles does not occur, a number of them would present later as sub fertile (or infertile) patients and would require treatment to have regular periods. There are also some abnormal conditions or diseases that may occasionally be the cause of irregular periods in the adolescent. It is therefore advised that if a girl has not established normal menstruation after the age of 16 years, she should see a gynaecologist. Most gynaecologists would normally and appropriately not start active treatment immediately unless an obvious abnormality is present.
However counselling will be done. If the condition persists after the age of 18 in the absence of any abnormality the patient is usually treated with contraceptive pills for about four cycles. Menstruation is regular when the oral contraceptive is used properly and after withdrawal of the pill, many of the patients would revert to a regular rhythm. If this fails a D & C (Dilation and Curettage) may be done. An additional number of patients would revert to a regular rhythm at this stage. For those who haven’t hormone therapy using the pill may be repeated. Where this fails further treatment may be deferred until pregnancy is desired when ovulation may be induced and cycles regularised with the use of fertility drugs.
It cannot be over-emphasised that irregularity of periods especially in the adolescent should be managed by a competent and well trained doctor. It is even more important in our environment as there is an association with future fertility and this society still places so much weight on reproductive ability.